Thursday, Jul 07 2011
• 11 a.m. (ET)

Mental Health and Aging

Americans who turn 65 this year can expect to live another 19 years on average. The majority will cope well with the physical and cognitive changes of late life. Others will experience mental disorders that are not part of normal aging. The symptoms of dementia and Alzheimer’s are commonly known. But a host of other mental health issues confronting seniors – from sleeplessness to anxiety – often go unrecognized and untreated. At the same time our aging population is growing, the U. S. faces a serious shortage of geriatric mental health care workers. Diane and her guests discuss the mental health challenges facing seniors.

Read an Excerpt: Dr. Agronin’s Book

Transcript

11:06:55

MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Many of us worry about the negative aspects of old age. Diseases like Alzheimer's and dementia can cause serious depression, but a number of mental health issues facing seniors are easily treatable. Joining me in the studio to talk about the normal parts of the aging process and how to recognize symptoms that require more help are Dr. Maria Llorente of the Washington D.C. VA Medical Center and Dr. Allan Anderson. He's with the American Association for Geriatric Psychiatry.

11:07:47

MS. DIANE REHMAnd we hope to have Dr. Marc Agronin of the Miami Jewish Health Systems joining us from NPR studio in New York City shortly. We'll let you know when he becomes a part of the conversation. But first, good morning to the two of you. It's good to have you with us. Dr. Llorente, let me start with you and get you to talk about the assumptions we make about society's aging.

11:08:25

DR. MARIA LLORENTESo there are a host of myths that exist in society about what happens as people get older. Oftentimes, it's thought that people are going to become physically disabled, that they're going to become depressed, that depression, for example, is just a normal part of aging. And also, sometimes people think memory problems are a normal part of aging and we can just simply expect that as we get older our memory is going to fail.

11:08:56

DR. MARIA LLORENTEAnd these really are myths. There are a whole host of very treatable conditions that can present with a variety of depressive symptoms and memory problems. And in addition to that, most older adults, while they may have one or two chronic illnesses, are really quite independent, able to live in the community and function very effectively as productive members of society. And so we really need to think more about what are the things that people can do to prevent some of these negative consequences of really disease, not so much aging.

11:09:34

REHMDr. Anderson, how is it that we've gotten to this belief in the myths of aging? Is it that previously we weren't able to deal with them or to treat them and so we assumed that they were a part of the aging process and now things are changing?

11:10:01

DR. ALLAN ANDERSONWell, one of the things that I think of is the continuing aging of our population so that if you go back to the early part of this century or last century, there were very few people who lived past 65. And in fact, probably the people that lived past 65 had a number of more serious concerns that couldn't be addressed by medicine back in those days. So now, we have, with technology and medical advances, the ability to have people age better into their older age because we can treat better illnesses like diabetes and chronic other diseases that afflict the people that turn 65 and older. So I think that that's part of the answer, too, it is the aging of our population and the better medical advances that we've made.

11:10:48

REHMAnd certainly advances in the mental health aspects as well as the physical questions and one has to wonder, going back to your point, Dr. Llorente, exactly how we know the difference between what is, for example, normal memory loss versus abnormal memory loss.

11:11:21

LLORENTESo there are things that we know does happen normally as we get older. Sometimes our ability to process things gets a little slower, but we really should be able to recall things even if given a little bit of time. One of the sort of earlier tips that really memory should be investigated is when an individual is having difficulty recalling and cannot remember, even despite thinking about it, you know, trying really hard to think of what it was they were trying to do.

11:11:56

REHMBut doesn't that happen to all of us at one time or another?

11:12:00

LLORENTESo if we're very, very busy, we're trying to retain in memory and attention seven, eight, nine different things, it can certainly happen. But you'll see that the majority of the time if you just stop, take a moment, retrace your steps and think back to what you were trying to recall, usually you can recall.

11:12:22

LLORENTEThe other thing that happens is that sometimes people will begin to have difficulty with tasks that were commonplace for them, being able to balance a checkbook, for example, you know, getting lost in certain locations that should be familiar. The family sometimes, too, is the first that begins to recognize or realize that the person is telling the same story as if for the first time, but three and four and five times over. These are the kinds of symptoms that oftentimes family members will notice that really should prompt some investigation.

11:12:54

REHMAnd joining us now from the NPR studio in New York and via Skype is Dr. Marc Agronin. He's medical director for Mental Health and Clinical Research with the Miami Jewish Health Systems in Miami, Florida. Good morning to you, sir, glad to have you with us.

11:13:21

DR. MARC AGRONINGood morning, great to be here.

11:13:22

REHMAnd Dr. Agronin, I know that you're responsible for thousands of patients. Yours is the largest geriatric psychiatry practice in the country. What are you seeing in regard to elderly patients and their problems?

11:13:48

AGRONINI would describe one of the main challenges as the earlier diagnosis of different forms of dementia, particularly Alzheimer's disease. So we're seeing individuals who are still relatively young, very active, active with their families, and now they're facing cognitive impairment.

11:14:06

REHMWhen you say relatively young, excuse me for interrupting, what do you mean by relatively young?

11:14:15

AGRONINIndividuals in their 60s, sometimes a little bit earlier. And I should add that for the average geriatric psychiatrist, we see patients around the age of 90 so someone in their 60s is quite young relative to our practice. But as you can imagine, when someone is 80 or 90 and suffering from a form of dementia such as Alzheimer's, it can be vastly different than someone in their 50s or 60s. And there aren't always the same programs in the community geared for some of those individuals or for their spouses and other loved ones serving as caregivers.

11:14:49

REHMNow, Dr. Anderson, would you call this an epidemic of Alzheimer's that's happening in this country?

11:15:00

ANDERSONYes, I would. And it's the combination, not only of the fact that we have not yet found a cure or a truly effective treatment to slow down the disease, but the ballooning of the population of people susceptible to the disease and that's just going to be magnified in the next 10 to 20 years.

11:15:16

REHMAnd why would you say there's this ballooning population that's susceptible? What is it that makes this group more susceptible beyond just simple aging?

11:15:31

ANDERSONWell, actually, that is the main risk factor for Alzheimer's dementia is aging and the fact is that the above 65 population is going to go from about 12.7 million to 20 million within the next 20 years. And without a cure, if a cure does not come, that's going to mean a tremendous number that will suffer from dementia.

11:15:51

REHMBut Dr. Agronin, has it always been with us and we just assumed that it was a product of aging and now we identify it as a disease?

11:16:08

AGRONINWell, in the past, the term senility, which really just means old, was used synonymously with dementia and so, you know, clearly we have to distinguish the two. The difference is that as people are living longer into the age range when they would develop Alzheimer's disease, we see more of it. Whereas, if you turn the clock back 40 or 50 years ago, the average person did not live into their 80s and 90s in which we see so much Alzheimer's so it was more common to see individuals with dementia related to stroke.

11:16:40

REHMNow, I don't want to make this program solely about dementia or Alzheimer's because surely there are an awful lot of other problems that the elderly face. Dr. Llorente, what about depression?

11:17:00

LLORENTESo depression is relatively common in the older adult, but it often doesn't present the same way with the same group of symptoms that a younger adult would. Sometimes, with an older adult, you'll see more in the way of physical complaints, sort of vague physical complaints. They often will go to their primary care provider. They don't typically come directly to mental health and so sometimes there's a very high cost in medical resource utilization that occurs because all of these medical symptoms are first being worked up to rule out a medical problem.

11:17:35

LLORENTEAnd sometimes just going through some basic symptoms that are commonly associated with a depressive disorder and considering that this individual may actually be suffering from depression, can save some of those resource uses.

11:17:48

REHMBut, of course, you've got to have a diagnosis first of depression and that may be hard to get because there aren't that many geriatric psychiatrists as you are, Dr. Anderson?

11:18:02

ANDERSONYes, that's true. We have a workforce of geriatric mental health specialists that is far lower than what we need currently and will be far -- even in a worse hole with regards to the numbers of clinicians in the future so we really need to increase our pipeline of trainees going into the field of geriatric mental health.

11:18:23

REHMDr. Allan Anderson, he's president of the American Association for Geriatric Psychiatry. He's medical director of The Bratton Memory Clinic in Easton, Maryland. We'll take a short break and be right back.

11:20:03

REHMAnd we're back talking about mental health issues in the elderly. Here in the studio, Dr. Allan Anderson. He's president of the American Association for Geriatric Psychiatry. Dr. Maria Llorente is associate chief of staff for Mental Health at the Washington D.C. Veterans Administration Medical Center. And on the line with us, Dr. Marc Agronin, medical director for Mental Health and Clinical Research with the Miami Jewish Health Systems in Miami, Fla. We do welcome your calls, 800-433-8850. Send us your email to drshow@wamu.org. Join us on Facebook or at Twitter.

11:21:04

REHMAnd here's a posting on Facebook for you, Dr. Agronin. Ravenna (sp?) says, "My father was a psychiatrist and growing up, both of my parents worked in nursing homes. As a child, I was aware of the special drought of decent mental health and medical care available to the aged. I don't think it's a new phenomenon. I think it's simply coming to light more now as baby boomers grow older. Would you agree?"

11:21:43

AGRONINI would agree with this and makes sense. Right now, if you look in the average nursing home, close to 80 percent of residents have one or more psychiatric diagnoses. And so, in essence, nursing homes are like psychiatric hospitals to some extent, given the many disorders, not only in dementia diagnosis, but depression anxiety disorders. And you really need individuals who understand the aging process and how these disorders can present differently later in life.

11:22:11

REHMAnd of course, that goes back to your point, Dr. Anderson, that there really are not a sufficient number of those trained in geriatric mental emotional disorders coming through the pipeline.

11:22:28

ANDERSONThat's true. And even when we've looked, as an organization, at our own graduates coming out of training programs in geriatric psychiatry, many of them end up not doing geriatric psychiatry. So they'll train in the field, but then for issues that are germane to their being able to earn a living, for instance, they will do more general psychiatry than geriatric psychiatry.

11:22:51

REHMIs it more profitable to do more general psychiatry than to do geriatric psychiatry?

11:23:02

ANDERSONGenerally, it is. Unfortunately, Medicare reimbursements have not kept up with inflation. And when I started my practice some 20 years ago, that wasn't the case. And since then, there's been cuts in Medicare payments to physicians or in years where there's not cuts, small increases that don't keep up with inflation. So now, if a graduate comes out of a training program in geriatric psychiatry, they're faced with accepting a lower reimbursement level for their additional training and hard work they've done to achieve that specialty status.

11:23:32

REHMDr. Llorente.

11:23:33

LLORENTEAnd one of the things that I'd like to add is that the complexity of the problems that the older adult has, particularly those with behavioral problems, with dementia, with depressive disorders is often times more significant and requires more time than what one would invest with a younger patient. And so, you know, you just heard Dr. Anderson say that there's been this reduction in reimbursement. But at the same time, the amount of time that is spent with an older adult is typically much longer.

11:24:02

REHMGive me an example, though, of how a doctor may be squeezed dealing with an elderly patient who perhaps needs more time.

11:24:14

LLORENTESo a very simple example is if you have someone that recently had a stroke or has Parkinson's disease or perhaps had a heart attack, they may move more slowly. So just something as simple as the amount of time it takes them to get from the waiting room into your office is consuming a little bit of time. They may have some communication difficulties and so it may take them longer to explain and to provide their history.

11:24:37

LLORENTEIf they have memory problems, you really often times need to have a caregiver, a family member. So now, you're getting history from two different people. And sometimes the caregiver may not even be available in your local area because they may have -- the patient may have retired to your area, but their family member may be somewhere away. So now you have to try to find them, contact them, call them. All of this is, you know, very time consuming.

11:25:01

LLORENTEAnd then, you have to take into consideration their medical problems, identify what medications they're taking. If you are going to be prescribing medication, you have to make sure that there aren't drug interactions or drug disease interactions. And so the amount of time that is invested by the geriatric mental health specialist can, as I said, be much longer than you would with the younger client.

11:25:24

REHMAnd Dr. Agronin, on that issue of medications, here's an email from Nancy who talks about the side effects of medications saying, "They're often missed in older adults and not recognized as causes of symptoms. This can easily blame old age caused by symptoms of medication."

11:25:54

AGRONINIt's very true because the average older individual on say an antidepressant is also taking eight, nine, maybe ten or more other medications which could have side effects. You also have the effects of whatever medical illnesses they're being treated for. And so not only do you have to separate out and distinguish potential side effects, but relevant to what Dr. Llorente was just mentioning, we also have to rely upon caregivers to give us that information. And that adds a whole other layer of communication in time, especially if the person in question has memory impairment and is unable to tell us the course of recent symptoms or side effects.

11:26:33

REHMDr. Marc Agronin is the author of "How We Age: A Doctor's Journey into the Heart of Growing Old." We're going to open the phones in just a moment. Dr. Agronin, why did you decide to turn to the care of the elderly?

11:26:59

AGRONINWhen I was doing my medical school training and then residency in psychiatry, I found that older individuals had the most fascinating life histories. You're able to understand their entire lifetime. And as challenging as it can be, it's really detective work where you have to piece together psychiatric, medical, social, historical factors together. It's a fascinating area. And to me, the stories that people bring to us really humanize them and show us that aging is different than what we often imagine. And there's so much good that we can do for individuals. This is what really drew me into the field.

11:27:36

REHMDr. Anderson, you?

11:27:39

ANDERSONYes, I think for many similar reasons. I enjoy the fact that this specialty gives us a connection to medicine that isn't always there in general psychiatry.

11:27:49

REHMWhat do you mean?

11:27:49

ANDERSONWell, I mean, for instance, during my patient visits, I will do some physical exam and neurologic examination. It's important to know how that person walks into the office and whether there are any neuromuscular impairments or disabilities that accompany their psychiatric or psychological symptoms. So it's a nice blend of medicine and psychiatry in practice.

11:28:10

REHMIs yours a completely or exclusively geriatric patient load?

11:28:19

ANDERSONYes, my current practice is exclusively geriatric.

11:28:21

REHMAnd what about you, Dr. Llorente?

11:28:24

LLORENTEWell, I feel very similar to the two previous comments that you've heard. I particularly loved my internal medicine rotations when I was in medical school. But what I really enjoyed was having the opportunity to talk with patients and to hear their life stories. I think that I'm extremely fortunate that I am able to work in the VA because part -- a very significant portion of the life story is their military experience and particularly their combat experiences and how that has impacted their mental health and their physical health.

11:28:57

REHMAnd I would think that for you anxiety disorders really come into play with that service-related part of their lives.

11:29:11

LLORENTEWe certainly treat a very large number of older veterans with Post Traumatic Stress Disorder. Both -- and I've, as I said, been very fortunate to be able to work with individuals that served in World War II, in Korea and now our Vietnam veterans are getting into their upper 50s and 60s. And we have a very large population of older veterans with Post Traumatic Stress.

11:29:36

REHMBut putting aside Post Traumatic Stress Syndrome as a part of service to the country, Dr. Anderson, what about anxiety disorders in those who haven't served?

11:29:52

ANDERSONSure. Anxiety disorders are very prevalent in the elderly population.

11:29:57

REHMGive me an example.

11:29:59

ANDERSONWell, the number one would be phobic types of disorders. So there are specific phobias that often don't necessitate treatment, but then other kinds of phobias that might lead to conditions, like panic disorder, where people then may shut themselves in and be afraid to go outside, a condition called agoraphobia. And then generalized anxiety disorder, which is often a lifelong disorder of excessive worrying that carries on into adulthood.

11:30:25

ANDERSONAnd unfortunately, I think because many of these don't often rise to the level, like in depression, of people being suicidal or having an acute imminent risk, they often might get undetected or untreated during their general life, but then they live with these into older age. And hopefully can get in front of someone with the expertise to tease out the anxiety symptoms and offer a treatment.

11:30:46

REHMDr. Agronin, you've probably seen a great deal of that.

11:30:51

AGRONINYes. In our nursing home, individuals come in for rehab and so you have someone who maybe a month before was completely functional. And then, they had an injury or an illness and now they're dependent on others. They have physical disability often and this can create an enormous amount of anxiety about the future. It can cause phobias of falling and then that interferes with rehabilitation. So it has a cascade effect and can reduce a person's ability to recover from a medical illness and make day-to-day life sometimes excruciatingly difficult.

11:31:26

AGRONINOne thing about anxiety is that it's often overlooked. We tend to think in terms of depression or we think in terms of someone having a normal reaction. But these disorders are pervasive and can cause enormous disability.

11:31:41

REHMWhen we think of memory loss, we associate it to a large extent with the elderly. How much of that memory loss, Dr. Agronin, do you see within the nursing home population?

11:32:03

AGRONINIt's an important point because one -- not all memory changes represent Alzheimer's disease. We see a lot of reversible conditions due to an injury, due to medication, due to a medical illness that can be treated. So we see that enormously prevalent in nursing home populations. Now, at the same time, the reason why so many individuals come into the nursing home is because they have Alzheimer's disease or some other dementia that limits them from being independent at home. That may be the very reason they came into the nursing home.

11:32:35

AGRONINAt the same time, there's a lot we can do for people. We don't have a cure yet for Alzheimer's disease, but it doesn't mean that we can't, with some medications, improve memory a little bit or at least try to treat a lot of the impediments for them to be fully functional, whether it's anxiety or depression or some other form of a psychological reaction to the situation.

11:32:56

REHMHow are you helping those with memory problems?

11:33:03

AGRONINOne, there are a number of medications on the market that can have modest effects on memory and Alzheimer's disease and several other forms of dementia. So we like to just give it...

11:33:11

REHMSuch as...

11:33:13

AGRONINAricept, Exelon, Razadyne, Namenda, those are the main players that we use. They're FDA indicated for Alzheimer's disease across the different stages. And again they can have modest benefits. At the same time, we want to make certain that someone is not taking commonly used medications, such as over-the-counter sleeping pills and others that can further impair memory because then whatever their baseline is, now you've reduced it because they're taking something. Even a medication that's commonly used as a statin medication in a certain number of individuals can cause some memory changes. And if you're already in a decline, it can have a larger effect than you'd see in someone who doesn't have that at his baseline.

11:33:56

REHMAnd you're listening to "The Diane Rehm Show." We have a great many listeners waiting. Going to open the phones, 800-433-8850. First to John in Little Rock, Ark. Good morning, you're on the air.

11:34:18

JOHNGood morning. Thank you. My call centers around memory loss and memory recovery. As a teenager, I had an auto accident with significant head trauma and has since caused me to lose or almost erase long term and intermediate term memory. Although my short term memory is good, you know, professionally, socially -- you know, I work well, run a business -- and wondering about a precursor to that, to dementia and some ideas for memory recovery.

11:34:52

REHMDr. Llorente.

11:34:54

LLORENTESo we are now recognizing that closed head injuries, traumatic brain injuries can, in fact, cause long term memory problems such as the ones that you are describing. There are some initiatives, and there are very large research projects now both in the Department of Defense as well as in the VA, looking at this question of how to retrain memory and how to try to recover memory. There are some cognitive retraining programs that, at this point, you know, really have a research base.

11:35:26

LLORENTEAnd often times the -- one of the primary recommendations is, as Dr. Agronin had mentioned, to be able to look at any other medications that one might be taking that could further impair your ability to concentrate or to reduce memory. And then, in some cases, engaging in memory exercises some individuals have found to be very helpful.

11:35:46

REHMWhat about simple things like crossword puzzles, Dr. Agronin?

11:35:52

AGRONINOne thing I want to emphasize in -- that the caller really made clear is that short term memory and long term memory, these are certain aspects of a person's mental capacity, but we have so many other strengths. We can't just limit it to one area because even though he has some degree of impairment, he's still running a business, he's functional, he's doing things. And that applies to anyone.

11:36:16

AGRONINThe evidence for brain training and crossword puzzles, things like that, is relatively modest. I tell people physical exercise is probably the most important thing they can do in terms of preserving memory because anything that gets a good blood supply to your brain is going to be good for your memory and other cognitive skills as well. Eating a diet that's rich in fruits and vegetables, and that's generally a brain healthy diet we recommend as well. There's not one single thing that's going to tip the balance for people.

11:36:46

REHMJohn, I hope you're getting lots of physical exercise.

11:36:52

JOHNI do and I appreciate the comments. And just a quick follow up, has head trauma been recognized as a precursor to dementia with memory loss?

11:37:04

REHMDr. Llorente.

11:37:06

LLORENTEI wouldn't use the word precursor. I would use the word risk factor so that not every person who has a head injury will develop dementia. But those individuals who develop dementia often times have a history of head injury.

11:37:20

REHMDr. Maria Llorente. She's with the Veterans Administration Medical Center here in Washington D.C. We'll take a short break here and more of your calls, your comments, when we come back. Stay with us.

11:40:04

REHMAnd welcome back. We'll go right back to the phones 800-433-8850. To San Antonio, Texas, good morning, Al, you're on the air.

11:40:18

ALYes, I'm a physician and I wanted to mention that the dementia of tertiary syphilis is indistinguishable from the dementia of Alzheimer's. Of course, syphilis is caused by a spirochete and Lyme's Disease is caused by a spirochete. Dr. Allan McDonald, a pathologist, found in 7 out of 10 brains of Alzheimer's patients that he took at Harvard -- from Harvard -- 7 out of the 10 had the DNA of the Lyme organism.

11:40:48

REHMDo you know about this, Dr. Anderson?

11:40:51

ANDERSONA bit, but not extensive.

11:40:54

REHMAnd how about you?

11:40:55

LLORENTEI'm not familiar with this.

11:40:56

REHMYou're not. And how about you, Dr. Agronin, Lyme Disease?

11:41:02

AGRONINSure. Lyme Disease, in rare cases, can cause an encephalopathy, that's true. We will test someone if, during the workup, we discover they've had potential exposure. We used to test for syphilis routinely and sometimes we still do in a dementia workup. This is interesting information. It's something which we -- it emphasizes the point that whenever you're working someone up for memory impairment, you need to cast a wide net. And this is what we miss sometimes. Individuals have reversible conditions.

11:41:33

REHMLet's go to Pontiac, Mich., good morning, Debbie.

11:41:38

DEBBIEGood morning, Diane. I just have to -- I'm a nurse, a registered nurse, and I've spent my entire career dealing with dementia patients. What I have found is that the social support for, not only the patient, but the family and good care giving and good medical care actually beats out, at a certain point, the medications that are prescribed that are so horribly expensive. I've got patients that are well into their dementia that really need to stop having the medication.

11:42:12

DEBBIEAnd if we could figure out some way to take that money and put it in supportive care or support for the families, I get a much bigger response all the way around than I do from giving them a pill.

11:42:27

REHMInteresting, Dr. Llorente.

11:42:29

LLORENTEI would completely agree with the comments of the caller. There are also some cultural components so that when you're working with different ethnic and racial minority populations, they would much rather keep their loved one in the home, in the community, providing care rather than institutionalizing them. So being able to provide that type of caregiver support often times will provide the assistance that the family needs to be able to keep their loved one at home, which is where they want and where the patient, him or herself, also wants to be.

11:43:05

REHMHere's an email from Jean in Hurst, Texas, who says, "The currently elderly tend to be part of the generation that view mental health issues as a weakness and would never consider any type of counseling." Have you run into that, Dr. Anderson?

11:43:30

ANDERSONYes, I have, but I do think that my experience has been that it's a bit overrated. I'm going to give you a personal example. My grandmother in her late 80s called me and told me she found this book on anxiety by a British physician and read it and wanted to know if I would recommend what else she could do. And it surprised me a bit. I think that -- now clearly, when the baby-boomers age, I think you'll see even a greater openness to mental health treatments, but I believe that the stigma is greatly reduced from what it used to be, say, 20 years ago.

11:44:03

ANDERSONAnd people, even of this generation, this older generation, are much more willing these days to come see a psychiatrist.

11:44:09

REHMDr. Agronin.

11:44:10

AGRONINThe current generation of individuals in their 80s and 90s often don't even have the language of psychotherapy. It's unfamiliar to them and, yet, the research that's starting to build is clear that people do just as well. I was working with a 96-year-old man who came to us and said that his life has been turned around because of psychotherapy.

11:44:31

AGRONINAnd I thought that's really remarkable that we don't tend to think of someone being able to change at that late in life, but this is one of the myths that, not only we face when we're younger, but older individuals as well. They're reluctant to engage in psychotherapy because they simply don't have the confidence or the hope that it can make a difference. And yet, again, this is where a geriatric-trained specialist can come in and bolster someone's confidence and ability to do this and really bring change.

11:44:57

REHMTo Raleigh, N.C., good morning, Sally.

11:45:02

SALLYGood morning. My question is if you were dealing with a person who is -- clearly have cognitive difficulties, they can't drive a car correctly, they fall a lot, they speak very slowly, which was not their habit, a lot of manifestations of some sort of problem, and yet, when you try to get them to go to the doctor, they're absolutely refusing and in denial. How do you -- what do you?

11:45:29

REHMDr. Agronin.

11:45:31

AGRONINWe face this all the time because, for some individuals, the idea of going to a psychiatrist can seem very frightening. I usually like to try to start with the internist or the primary care specialist, someone that this individual trusts that they will see. Sometimes we can remotely, so to speak, begin to implement treatment, but it's difficult when someone absolutely refuses. And sometimes families have to go down the road of even legal measures or guardianship to pressure someone to get involved.

11:46:01

AGRONINIt comes down largely to the relationship that a person has with their children and sometimes those can be very difficult. So we find that if we can intervene on that level, sometimes we can get people into treatment. Unfortunately, there are many situations where it becomes a battle.

11:46:18

LLORENTESometimes, too, trying to identify the individual that that person has listened to in the past, it may be a child. Not infrequently, it might be a sibling or if they have surviving aunts or uncles, but someone that, you know, they respect. Sometimes engaging that person to provide assistance and to try to convince the individual to come into treatment can be helpful.

11:46:43

REHMAnd to Jeanine in Rockville, Md., good morning, you're on the air.

11:46:50

JEANINEOh, good morning, good morning. Thank you for taking my call.

11:46:52

REHMSure.

11:46:53

JEANINEMy question is two-fold. I have one parent, a surviving parent, who has lost a sister to breast cancer, which means that my mother buried her daughter. And I've noticed that ever since, you know, in the last, I would say, three years since the passing of my sister, the grief has just -- she's just not the same. She's -- there's a sense that she's just kind of given up, kind of a sense of she just isn't the same.

11:47:28

JEANINEHer memory is not quite as -- she's not as sharp. And I was wondering how a traumatic event like that affects the neurological, possibly, or chemical effects of the brain. Is there something, you know, I don't -- I'm not sure exactly what the correct terminology is.

11:47:45

REHMSure, Dr. Anderson.

11:47:47

ANDERSONCertainly. This is an area that, I think, we need more research in. But there clearly are individuals who, when suffering acute losses, have symptoms that might, for instance, resemble dementia. They may develop depressive symptoms, but, also, these cognitive changes and may have a drop in function as a result. And it's important to get those people in front of clinicians that can identify that and offer some treatment.

11:48:12

REHMDo you agree, Dr. Agronin?

11:48:15

AGRONINI do. We don't think twice when treating someone for physical pain. We wouldn't say they have to bear the pain and, yet, often we allow people to go on with terrible grief thinking that somehow they have to be able to bear it. It's a form of suffering and whether it's talk therapy or sometimes even medications when it crosses into depression, it's important to actively treat these symptoms.

11:48:36

REHMIt's interesting. I have an email from Dale in Florida who says, "Wouldn't it be abnormal not to be depressed? Isn't it a problem with the myriad of age-related problems, especially the health and medical ones?" Dr. Agronin.

11:49:05

AGRONINIt's so important to emphasize this point that just because someone gets older doesn't mean that they become depressed. In fact, if you look at most surveys of well being, that people have higher degrees of well being as they get older rather than lower ones and rates of severe major depression go down. It's important to distinguish between sadness and a normal emotional reaction someone might have associated with parts of the aging process and depression because depression is an illness.

11:49:32

AGRONINIt's not a normal part of aging. It needs to be recognized and treated. We have, again, this myth that old age is a time of sadness and loss and decline. And, yet, if you talk to older individuals and you survey them, you find that that is simply not the case.

11:49:48

REHMDr. Llorente, here's an email from Rebecca in Vermont who says, "How can younger adults prepare for age-related cognitive losses that appear to run in the family? Our fear for ourselves can complicate our efforts to be helpful to our elders."

11:50:14

LLORENTEAnd that's a great question. And we do get that question very often from the adult grown children of our older patients with memory problems. Dr. Agronin alluded a little while ago and specifically suggested exercise and there is no question that mitigating various risk factors for developing dementing illnesses or, conversely, some of the things that actually cause and can contribute to things like strokes, can be very, very helpful.

11:50:57

REHMAnd here's another -- a number of emails asking us to talk more about the social support available to people versus medication. One person says that social support does not have a lobby in Washington, but big pharma does. Dr. Anderson.

11:51:23

ANDERSONWell, it's an interesting point. We have seen many, many years of a focus on pharmacologic treatments for ailments like Alzheimer's disease and dementia. And, unfortunately, when that has happened, at times that's neglected the other side of the treatment being the social or psychological. At our center, we emphasize the psychological. I mean, we realize that the medications, for instance, for dementia have a modest benefit. It's vital that things other than medicine are offered, especially to the family members who are struggling with their family member afflicted with dementia.

11:51:55

ANDERSONSo we consider that a very important point and we have counselors that are trained to deal with that at our center. And I think many memory centers would have similarly trained people.

11:52:04

REHMDr. Agronin.

11:52:06

AGRONINI would agree completely with Dr. Anderson. We spend as much time with caregivers often as we do with the family members who are identified as the patients. Whether it's the Alzheimer's Association or the Area Agency in Aging or other senior centers, there are resources in the community that can be taken advantage of that offer programs and these can make a huge difference.

11:52:30

AGRONINOne point that's come across here, and is very true, that the environment makes a difference, the support makes a difference, often allowing us to either forego or at least use less medications when you have those supports in place.

11:52:43

REHMAnd you're listening to "The Diane Rehm Show." Dr. Agronin, tell us about your group of merry widows.

11:52:52

AGRONINThis is a group -- there are actually three women who came to me initially because their husbands were suffering from Alzheimer's disease. They needed help, not only to help them, but, also, each one of them was suffering from varying degrees of depression. Their husbands, we worked with over the years. When they passed -- all of them passed away, the three women actually moved together into our assisted living facility.

11:53:15

AGRONINThey were able to overcome their depression. They really threw themselves into new lives within the center and serve as an inspiration for so many other people there. They show that there is life, not only active living and happy living even when you're working with -- serving as a caregiver, but, also, beyond it as well.

11:53:34

REHMWell, we have another problem, which is paying for medical care for the elderly, especially mental health care, Dr. Llorente.

11:53:49

LLORENTESo I think that there's been enough in the news recently about health care and overall health care expenditures in this country. One of the things to sort of keep in mind, though, is that a disease like depression, for example, can markedly increase the costs that are associated with health care when it goes untreated. Those individuals, for example, that have diabetes and depression typically cost two to three times more in terms of health care utilization than those patients who just have diabetes without the depression.

11:54:20

LLORENTESo it really underscores the importance of trying to identify these disorders as soon as possible, primarily through screening, for example, in the primary care setting and then intervening as early as possible because short term, you can really have a significant impact on long term costs.

11:54:39

REHMBut Dr. Anderson with Medicare, Medicaid cutbacks perhaps becoming reality, how are the elderly going to pay for these services?

11:54:57

ANDERSONWell, certainly, that is going to be an important question as we look at what happens with health care reform. I also think -- and I think that we, as an organization at AAGP, feel that this is an opportunity. We may need to revamp the way that we look at how we provide care and focus much more, for instance, on educating and training other clinicians to do the work that is needed to be done in this population because, clearly, the number of trained geriatric psychiatrists is diminishing, not growing.

11:55:27

ANDERSONSo we need to come up with probably some new models and we see it as an opportunity to do that and then, therefore, help this population to deal better with the mental illness they have.

11:55:35

11:55:46

AGRONINIt's true. We all -- we all face many of the same disorders that we're treating with more intensive geriatric and geriatric psychiatry help. Rather than costing more in the end, my guess certainly reduces the costs. And this is a message that needs to get out there because by not supporting more preventative issues, we end up paying for it in the end.

11:56:08

REHMWell, and in medical schools, young people are saying I can't afford that kind of training because it's not going to pay me back in the end as much as a, perhaps, psychiatry might. We've got to totally revamp that educational process to reward those young people who go into these fields of medicine. I want to thank you all so much.

11:56:41

REHMDr. Maria Llorente of the Veterans Administration Medical Center here in Washington. Dr. Allan Anderson, he is president at the American Association for Geriatric Psychiatry, medical director of The Bratton Memory Clinic in Easton, Maryland, and Dr. Marc Agronin, medical director for Mental Health and Clinical Research with the Miami Jewish Health Systems in Miami, Florida and author of the book, "How We Age: A Doctor's Journey into the Heart of Growing Old." Thanks for listening all. I'm Diane Rehm.

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